Vaginal Birth After C-Section: New Guidelines Say It’s A Safe Option

“Once a c-section, always a c-section,” is a century old opinion of Dr. Edwin Cragin.

However, despite the many changes to obstetric care, it seems to continue to be held by many.

Current research and now current guidelines tell us this isn’t necessarily true.

The Royal College of Obstetricians and Gynaecologists has released new statistics and new guidelines which show vaginal birth after a c-section (VBAC) is a safe and probable option for birthing mothers.

The new information shows just how outdated the ‘once a c-section always a c-section’ opinion really is.

Mothers Attempting A VBAC Are Just As Likely As First Time Mothers To Have A Vaginal Birth

The new guidelines released by the RCOG state that women attempting a vaginal birth after a previous c-section have a success rate of around 75%, comparable to first time mothers.

Even for women with two previous c-sections, the VBAC success rate is around 71%.

For VBAC mothers with a previous vaginal birth, the VBAC success rate rises to 85-90%.

This means that depending on a mother’s specific situation, she has a pretty good chance of having a successful vaginal birth following a previous c-section.

If 71-90% of VBAC mothers are able to have a vaginal birth, it seems the that once a c-section, always a c-section is far from true for most birthing women.

RCOG Says VBAC Is Clinically Safe

The new guidelines by RCOG state that vaginal births are a clinically safe option for the majority – even for women with a previous c-section – and they carry a lower risk of complications than a c-section.

These new guidelines will hopefully help to reduce the very high number of c-sections.

In England, one of four birthing women will have a c-section. In Australia and the United States, the figure is closer to one in three. This is much higher than the World Health Organization’s (WHO) recommendations of a c-section rate of 10-15%. Their research has found that beyond 15%, a c-section does not save additional lives.

Some private hospitals in England and other countries have c-section rates near 50%. With elective c-sections accounting for 10% of births, it’s possible these new guidelines will help women make fully informed choices about their births.

In some situations, doctors may advise women to choose a c-section, as it allows them to manage and control the birth, in the hope of avoiding unexpected emergency complications. However, even the most routine c-section carries risk as it’s major abdominal surgery – more risks than a vaginal birth for the majority of women. This is not to mention risks for the baby too.

The guidelines published on October 1, 2015, summarise the latest research regarding vaginal birth. Professor Janesh Gupta, the lead author said, “Women can be assured that in most cases it is possible and safe to have a vaginal birth after a previous caesarean section. This guideline can be used to aid doctors in their assessment of individual women and, unless there are clinical reasons why a vaginal birth should not be attempted, help inform the woman and her partner of her choices and the risks involved with either vaginal birth or a repeat caesarean section.”

The Newly Published Guidelines Are Important

With England seeing a one in four c-section rate and other western counties like the US seeing a one in three c-section rate, this newly published information may help more countries to meet the WHO guidelines of a 10-15% c-section rate.

Despite the ‘once a c-section always a c-section’ opinion being nearly a century old, it’s been followed for decades, and continues to be followed by many clinicians and hospitals. Up-to-date guidelines encourage clinicians to learn about current research, and change their practices to reflect the current research. Hopefully this will be the case.

When necessary, c-sections are a lifesaving tool. However, when used electively, the benefit of the surgery is unlikely to outweigh the risks. While vaginal birth isn’t without risk, in most situations it is a lower risk option, even among VBAC mothers.

Where Did ‘Once A C-Section, Always a C-Section’ Come From?

In the early 20th century, c-section was risky surgery, in an era of major risk of infection and haemorrhage. It often included vertical cuts on the abdomen and/or uterus. The large scar was a risk for rupturing during a subsequent birth. Dr. Edwin Cragin said, ‘once a c-section always a c-section,’ as a caution to doctors about the serious decision to perform a c-section. It was also relevant to the time, as those having c-sections often needed them due to a pelvic anomaly (such as rickets, a nutritional problem which is no longer common) making a successful VBAC unlikely.

As surgical practices advanced, including safer anaesthesia options, lower risks of infection and better suturing skills, c-sections became a bit less risky — though still not without risk. This lead to doctors performing more and more c-sections — until now, where we’re seeing 20-50% c-section rates in some places.

These high rates, as well as pelvic anomalies being rare, means many women are having c-sections without medical indication. With low transverse and double sutured c-section scars becoming a norm, the risks associated with VBAC birth also decreased. This made the, ‘once a c-section, always a c-section’ stance no longer an evidenced based belief.

Do These Guidelines Mean I Should Have A Vaginal Birth?

Guidelines, research and statistics help us to make informed decisions. But we must remember that each woman, baby and birth are unique. What this information does tell us is that for the majority of women – including those with a previous c-section – a vaginal birth is likely the safest option.

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Birth is a normal physiological process — part of the reproductive lifecycle — which our bodies are designed to do. While even the most natural of process can veer from normal, evidence does show planning for a vaginal birth is safe for the majority of women. With VBAC success rates at 71-90% and vaginal birth carrying less risk of complications, these new guidelines indicate a VBAC is an important option that should be made available to birthing women.

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Maria Pyanov CPD, CCECONTRIBUTOR

Maria Silver Pyanov is a mama of four energetic boys and one unique little girl. She is also a doula and childbirth educator. She's an advocate for birth options, and adequate prenatal care and support. She believes in the importance of rebuilding the village so no parent feels unsupported.

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